It’s the mantra of The Center for Life Insurance Disputes that every life insurance claim needs to be thoroughly and properly investigated before a beneficiary accepts an insurer’s decision to deny their claim. The investigation of life insurance claims is a combination of many things. One of those things is a thorough review of the conditions of the policy. Most accidental death policies have exclusions to coverage, which typically favor the insurer.
Another factor of life insurance claims is the understanding of medical information. Thoroughly researching and investigating medical history, as well as medical conclusions of the insurer, are critical to a fair claim review.
While there are many other things that encompass a life insurance claim investigation, this particular claim dealt with an Accidental Death policy, policy exclusions, and a toxicology report on the deceased.
For this client we were challenged on whether the accidental death claim should be paid or denied because the insured had several pharmaceutical substances in her system when she died.
Nearly every accidental death policy has an exclusion to benefits related to the insured having medications and/or substances in their body at the time of death. Many people think that the mere presence of medications, alcohol or other substances necessarily means the claim will be denied. While it’s true that these things often exclude coverage, it’s not always the case.
We represented the beneficiary who was trying to claim benefits on her sister’s accidental death policy. The toxicology report demonstrated that the insured had four separate substances in her blood when she died. On the face of it, this would be an automatic decline for benefits under the policy exclusions clause.
Our experts investigated the substances and then cross referenced them with dosages. We then obtained prescriptions and medical records for our doctors to analyze. Had the Center for Life Insurance Disputes not intervened, we have no doubt that this claim would have been denied.
Instead, after receiving our report and conclusions the insurer agreed with our conclusions and paid the claim. What we uncovered was that even though the pharmaceutical substances were cataloged in the toxicology report, they were irrelevant to the conditions and the events of the cause of death. The insurer agreed and the claim was promptly paid.
toxicology report for accidental death claim